source: FOIAVistA/tag/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWPE2.m@ 628

DVBCWPE2 ;ESW/ PTSD WKS TEXT - 2 ; 10 Oct 2000
 ;;2.7;AMIE;**34**;Apr 10, 1995
 ;
 ;
TXT ;
 ;;E. Assessment of PTSD
 ;;
 ;;    * state whether or not the veteran meets the DSM-IV stressor criterion
 ;;    * identify behavioral, cognitive, social, affective, or somatic symptoms
 ;;      veteran attributes to PTSD
 ;;    * describe specific PTSD symptoms present (symptoms of trauma
 ;;      re-experiencing, avoidance/numbing, heightened physiological arousal,
 ;;      and associated features [e.g., disillusionment and demoralization])
 ;;    * specify typical frequency, and severity of symptoms
 ;;TOF
 ;;F. Psychometric Testing Results
 ;;
 ;;   * provide psychological testing if deemed necessary.
 ;;   * provide specific evaluation information required by the rating board or
 ;;     on a BVA Remand.
 ;;   * comment on validity of psychological test results
 ;;   * provide scores for PTSD psychometric assessments administered
 ;;   * state whether PTSD psychometric measures are consistent or inconsistent
 ;;     with a diagnosis of PTSD, based on normative data and established
 ;;     "cutting scores" (cutting scores that are consistent with or supportive
 ;;     of a PTSD diagnosis are as follows: PCL - not less than 50;
 ;;     Mississippi Scale - not less than 107; MMPI PTSD subscale a score
 ;;     greater than 28; MMPI code type: 2-8 or 2-7-8)
 ;;   * state degree of severity of PTSD symptoms based on psychometric data
 ;;     (mild, moderate, or severe)
 ;;   * describe findings from psychological tests measuring other than
 ;;     PTSD (MMPI, etc.)
 ;;
 ;;G. Diagnosis:
 ;;
 ;;    1. The Diagnosis must conform to DSM-IV and be supported by the findings
 ;;       on the examination report.
 ;;    2. If there are multiple mental disorders, delineate to the extent possible
 ;;       the symptoms associated with each and a discussion of relationship.
 ;;    3. Evaluation is based on the effects of the signs and symptoms on
 ;;       occupational and social functioning.
 ;;
 ;;    NOTE: VA is prohibited by statute from paying compensation for a disability
 ;;    that is a result of the veteran's own ALCOHOL OR DRUG ABUSE, whether based
 ;;    on direct service connection, secondary service connection, or aggravation
 ;;    by a service-connected condition. Therefore, when alcohol or drug abuse
 ;;    accompanies or is associated with another mental disorder, separate,
 ;;    to the extent possible, the effects of the alcohol or drug abuse from
 ;;    the effects of the other mental disorder(s). If it is not possible
 ;;    to separate the effects, explain why.
 ;;
 ;;H. Diagnostic Status
 ;;
 ;;      Axis I disorders
 ;;      Axis II disorders
 ;;      Axis III disorders
 ;;      Axis IV (psychosocial and environmental problems)
 ;;      Axis V (GAF score - current)
 ;;
 ;;I. Global Assessment or Functioning (GAF):
 ;;
 ;;    NOTE: The complete multi-axial format as specified by DSM-IV may be required
 ;;    by BVA REMAND or specifically requested by the rating specialist. If so,
 ;;    include the GAF score and note whether it refers to current functioning.
 ;;    A BVA REMAND may also request, in addition to an overall GAF score,
 ;;    that a separate GAF score be provided for each mental disorder present when
 ;;    there are multiple Axis I or Axis II diagnoses and not all are service-
 ;;    connected. If separate GAF scores can be given, an explanation and
 ;;    discussion of the rationale is needed. If it is not possible, an explanation
 ;;    as to why not is needed. (See the above note pertaining to alcohol or drug
 ;;    abuse, the effects of which cannot be used to assess the effects of
 ;;    a service-connected condition.)
 ;;
 ;;J. Competency:
 ;;
 ;;   Competency, for benefits purposes, has a special meaning,
 ;;   and refers ONLY to veterans' ability to manage benefit payments in their own
 ;;   best interests without restriction, and not to any other subject. State
 ;;   whether the veteran is capable of managing his/her or her benefit payments
 ;;   in the individual's own best interests (a physical disability which prevents
 ;;   the veteran from attending to financial matters in person is not a proper
 ;;   basis for a finding of incompetency unless the veteran is, by reason of that
 ;;   disability, incapable of directing someone else in handling the individual's
 ;;   financial affairs).
 ;;
 ;;K. Other Opinion:
 ;;
 ;;   Furnish any other specific opinion requested by the rating
 ;;   board or BVA remand (i.e.,furnish the complete rationale and citation of
 ;;   medical texts or treatise supporting opinion, if medical literature review
 ;;   was undertaken). If the requested opinion is medically not ascertainable
 ;;   on exam or testing please state WHY. If the requested opinion can not be
 ;;   expressed without resorting to speculation or making improbable assumptions
 ;;   say so, and explain why. If the Opinion asks "... is it at least as likely
 ;;   as not..", fully explain the clinical findings and rationale for the opinion.
 ;;
 ;;L. Integrated Summary and Conclusions
 ;;
 ;;   1. Describe changes in PSYCHOSOCIAL FUNCTIONAL STATUS and QUALITY of LIFE
 ;;      since the last exam (performance in employment or schooling, routine
 ;;      responsibilities of self care, family role functioning, physical health,
 ;;      social/interpersonal relationships, recreation/leisure pursuits)
 ;;   2. Describe linkage between PTSD symptoms and aforementioned changes in
 ;;      impairment in functional status and quality of life. 
 ;;        Particularly in cases where a veteran is unemployed, specific details
 ;;        about the effects of PTSD and its symptoms on employment are especially 
 ;;        important.
 ;;   3. If possible, describe extent to which disorders other than PTSD
 ;;      (e.g., substance use disorders) are independently responsible for
 ;;      impairment in psychosocial adjustment and quality of life. If this is not
 ;;      possible, explain why (e.g., substance use had onset after PTSD
 ;;      and clearly is a means of coping with PTSD symptoms).
 ;;TOF
 ;;   4. If possible, state prognosis for improvement of psychiatric condition
 ;;      and impairments in functional status.
 ;;   5. Comment on whether veteran should be rated as competent for VA purposes
 ;;      in terms of being capable of managing his/her benefit payments in his/her
 ;;      own best interest.
 ;;
 ;;
 ;;Signature:                              Date:
 ;;END